Hepatitis C

Background

• Bloodborne transmission
• NO acute phase
• >75% progress to chronic hepatitis C infection
• Disease course depends on comorbidities (e.g. alcohol use, HIV status, etc.)
• May progress to cirrhosis, +/- hepatocellular carcinoma

Clinical Features

Jaundice of the skin

Pediatric jaundice with icterus of sclera.

• Asymptomatic during first few years
• Symptoms occur once cirrhosis has developed
• Malaise, weakness (from electrolyte derangements)
• Abdominal pain
• Ascites, SBP (fever, abdominal tenderness)
• Altered mental status due to hepatic encephalopathy
• Coagulopathy
• GI bleed

Differential Diagnosis

Causes of acute hepatitis

• Acetaminophen toxicity (most common cause of acute liver failure in the US)
• Viral hepatitis
  • Hepatitis A
  • Hepatitis B
  • Hepatitis C
  • Hepatitis D
  • Hepatitis E
  • HSV
  • Epstein-Barr virus
  • Varicella zoster virus
• Toxoplasmosis
• Acute alcoholic hepatitis
• Toxins
  • Mushroom toxicity
    • Crotinarius mushrooms
    • Gyromitra mushrooms
    • Amanita mushrooms
• Ischemic hepatitis
• Autoimmune hepatitis
• Wilson's disease

Evaluation

Interpreting Acute Hepatitis Panel Results

Anti-hepatitis A, IgM	Hepatitis B surface antigen	Anti-hepatitis B core, IgM	Anti-hepatitis C	Interpretation
Positive	Negative	Negative	Negative	Acute hepatitis A
Negative	Positive	Positive	Negative	Acute hepatitis B
Negative	Positive	Negative	Negative	Chronic hepatitis B infection
Negative	Negative	Positive	Negative	Acute hepatitis B; quantity of hepatitis B surface antigen is too low to detect
Negative	Negative	Negative	Positive	Acute or chronic hepatitis C; additional tests are required to make the determination

Management

Complications of cirrhosis

• Ascites
• Esophageal varices
• Hepatic encephalopathy
• Spontaneous bacterial peritonitis
• Hepatorenal syndrome
• Portal hypertension
• Upper gastrointestinal bleed
• Hepatocellular carcinoma

Outpatient HCV treatment may include:

• Interferon-α or pegylated interferons
• Ribavirin
• Direct-acting antiviral agents (boceprevir, telaprevir, simeprevir, sofosbuvir, Harvoni, etc.)

Disposition

• Often complex and should be based on presence/absence of acute complications
• If no complications present, discussion with patient's primary care provider or gastroenterologist recommended

See Also

• Cirrhosis
• Ascites, SBP
• Hepatic encephalopathy
• Hepatorenal syndrome
• Upper gastrointestinal bleed